Declaration:

Have you the proposer, any director/partner of the business, either personally or in any business capacity:

◦ Been bankrupt, insolvent, subject to bankruptcy/ insolvency proceedings / Yes / No
◦ Had a proposal refused or declined / Yes / No
◦ Had insurance cancelled or special terms imposed / Yes / No
◦ Had any convictions for criminal offences / Yes / No

Business Details:

◦ Renewal Date
◦ Legal Trading Status / CharityClubLimited CompanyPartnershipPublic LimitedReligious OrganisationSole ProprietorSole Trader
◦ Business Name
◦ Type of Care Home/Care / Nursing
Residential (elderly)
Assisted Living
Children’s
Other
If other, please give details.
◦ Proposers Title / MrMissMsMrsDr
◦ Proposers Forename
◦ Proposers Surname
◦ Telephone Number
◦ Email
◦ Website / www.
◦ Street Number/Name
◦ Town/City
◦ County
◦ Postcode
◦ Year Business Established
◦ Years at Current Address
◦ Registration - Appropriate Regulatory Body / Yes No
If yes, please give details.
◦ Total Number of Employees
◦ Number of Qualified Nurses
◦ Number of Auxiliary Nurses
◦ Current Insurer
◦ Accidents or Claims in the Last 5 Years / Yes No
If yes, please give details.
◦ Material Facts / None
The business is not self-contained with its own access
The location has a history of flooding
The property is made of non-standard materials
The property/adjacent property has signs of Subsidence
The proposer is not the sole occupant of the premises
There is a cash machine (ATM) at the premises

Details of Residents:

◦ Minimum Age for Residents
◦ Maximum Number of Residents
◦ Number of Residents Currently in Home
◦ Residents Detained Under the Mental Health Act / Yes No
◦ Nature/Severity of Illnesses/Disabilities Cared for
◦ Any Residents with a History of / Violence
Aggression
Sexual Offences
Arson
◦ Any Incidents of Assault/Abuse in the Last 5 Years / Yes No
If yes, please give details.
◦ Does the Home Offer Surgery Post-Operative Care / Yes No
◦ Services Available to Residents in the Home / (e.g. physiotherapy etc)
◦ Are PL & PI checks undertaken on Practitioners / Public Liability Professional Indemnity
◦ Do You Provide Care in the Community / Yes No
◦ Do You Provide Sheltered Accommodation / Yes No
◦ Do You Provide day Care / Yes No
◦ Do You Provide any Recreational Facilities / Yes No
If yes to any of the last 4 questions, give details.
◦ Residents/Patients Needs Assessed/Documented / Yes No
◦ Are Staff in Attendance 24 Hours a Day / Yes No

Health and Safety:

◦ The Home Complies with H&S, COSHH and other Environmental Regulations / Yes No
◦ Home has a written H&S Policy, and Details are |Passed to all Employees / Yes No
◦ Does the Home Have an Action Plan for Cleaning up Spillages / Yes No
◦ Regulators Fitted restricting Temperature of Hot Water/Radiators/Pipes (43˚c) / Yes No
◦ Pre-employment Health Questionnaires Completed by all Employees / Yes No
◦ Are specific enquires made relating to Back Problem History / Yes No
◦ All Staff Properly Trained in Lifting Techniques and also Documented / Yes No
◦ Are Training RecordsDocumented and then Signed by everyEmployee / Yes No
  1. Buildings Cover:

◦ Do you require Buildings Cover / Yes No
If no, continue to section 2 Contents Cover.
◦ Location / ArcadeBusiness ParkBuilding Otherwise Occupied As DwellingsCovered Shopping CentreCity CentreDomestic PremisesHigh StreetOffice PremisesIndustrial UnitParadePrecinct
◦ Occupancy / 24 HoursBusiness HoursDay OnlyNight OnlyNon SeasonalNot Business HoursPrivate DwellingSeasonalUnoccupied
◦ Is the Building Listed / Grade 1 ListedGrade 2 ListedNot listedPreservation Order
◦ Year Property Built
◦ Is the Building in a GoodState of Repair / Yes No
◦ Number of Floors
◦ Construction of Walls (brick, stone etc)
◦ Construction of Roofs (tile, slate etc)
◦ Percentage of Flat Roofs / % 102030405060708090100
◦ Construction of Floors (concrete, wood etc)
◦ Building Purpose Built or Converted / Purpose Built Converted
◦ Required Cover (select only one) / All Risks
All Risks plus Accidental Damage
All Risk plus Subsidence
All Risks plus Accidental Damage & Subsidence
◦ Buildings Cover Basis (select only one) / Reinstatement Indemnity
◦ Buildings / £
◦ Landlords Fixtures & Fittings / £
◦ Tenants Improvements / £
◦ Is Terrorism Cover Required / Yes No
◦ Loss of Rent Payable/Receivable / £
  1. Contents Cover:

◦ Do you require Contents Cover / Yes No
If no, continue to section 3 Money Cover.
◦ Frozen/Refrigerated Food / £
◦ Deterioration of Stock Cover for Food / Yes No
◦ Computers Sum Insured / £
◦ Other Electrical Equipment Sum Insured / £
◦ All Other Contents / £
◦ Specified Items / £ (please give details)
£ (please give details)
◦ Residents Effects (per person) / £
  1. Money Cover:

◦ Do you require Money Cover / Yes No
If no, continue to section 4 Goods In Transit.
◦ Money During Hours / £
◦ Money Out of Hours, in Safe / £
◦ Money in Transit/Bank Night Safe / £
◦ Money Out of Hours, Not in Safe / £
  1. Goods in Transit:

◦ Do you require Goods in TransitCover / Yes No
If no, continue to section 5 Business Interruption.
◦ Own Vehicles / £
◦ Hauliers / £
  1. Business Interruption:

◦ Do You Require Business InterruptionCover / Yes No
If no, continue to section 6 Other Options.
◦ Gross Profit/Revenue / £
◦ Indemnity Period (months) / 12 months24 months36 months
◦ Loss of Registration Certificate Cover / Yes No
  1. Other Options:

◦ Legal Expenses / Yes No
◦ Loss of Licence / Yes No
◦ Equipment Breakdown / Yes No
◦ Personal Accident / Yes No
  1. Liabilities Cover:

◦ Employers Liability / Yes No
◦ Public Liability / Yes No
◦ Select Limit of Indemnity / £ 2,000,0005,000,000
◦ Medical Malpractice Liability / Yes No
◦ Total AnnualTurnover / £
◦ Wage Roll (next 12 months) / Clerical £ Manual £ Work Away £
Other £ (please give details)
Other£ (please give details)
Other £ (please give details)
◦ Does the Business Provide Domiciliary Care / Yes No

If you have selected Buildings and/or Contents cover, please complete the following information.

◦ Alarm Type / ABC
Audible
Central Station - Dial-Up Line
Central Station - Direct Line
Digicom
Dualcom
High Decibel Internal Sounder
Line - Site Security Office
Paknet
Police - Direct Line
Redcare
Redcare - GSM
Visual
◦ Police Response / Level 1
Level 2
Level 3
No Police Response
◦ Additional Security Details / Close Shackle Padlock – 5 (or more) Levers
Open Shackle Padlock – 5 (or more) Levers
Rim Lock
Rim Lock Automatic Deadlock
Rim Lock Automatic Deadlock – BS3621
Hinge Bolts
Steel Lined Doors
Bars on Windows
Anti-Ram Raid Bollards
External Grills
Proposer/Family Members/Employees Residing
Rim Deadlocks
Internal Grills
Shutters - Metal
Shutters – Wooden
Standard Non-Iron Grills
Encasement Devices on Computer Equipment
Lock Down Devices
Town Centre CCTV
Private CCTV
Other Monitored CCTV
24 Hour Security
Security Patrols
Guard Dogs
◦ Risk Improvement Features / Sprinklers
Fire Blankets
Fire Extinguishers
Smoke Detectors
◦ Fire Alarm / Bells Only Automatic/Redcare System
◦ Premises Heated by / Gas or Electric Conventional Central Heating Pipes
Other Electric Heating (excluding portable/non-fixed)
Other

Please email the completed form to and we will respond within 48 hours.

Any Additional Information